30-Day Wait Before Tubal Sterilization Is Unjust, Say Ob/GYN Experts

New article in the American Journal
of Obstetrics & Gynecology urges obstetricians to advocate for change to
eliminate health care injustice in access to elective tubal sterilization

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Philadelphia, PA, May 7, 2015

Current U.S. health policy requires Medicaid
beneficiaries to wait 30 days before tubal sterilization. Ob/gyn experts argue
that this violates health care justice as elective tubal sterilization is
readily available to women with a private source of payment. Writing in the American
Journal of Obstetrics & Gynecology, they urge obstetricians to advocate
for change to eliminate health care injustice in women’s access to elective
tubal sterilization.

One of the most common forms of contraception in the U.S.
is tubal sterilization after childbirth, which accounts for about half of the
half million female sterilization procedures done every year. The timing has
the advantage of one-time hospitalization, which results in ease and
convenience for the woman. The U.S. Collaborative Review of Sterilization Study
indicates the high efficacy and effectiveness of postpartum tubal
sterilization.

But while elective tubal sterilization is readily
available to women with a private source of payment, this is not the case for
Medicaid beneficiaries who are required to wait 30 days, which can be
impractical unless the paperwork is concluded well in advance of the birth.
“Regardless of who pays, the ethical and legal standard for the performance of
elective tubal sterilization for permanent contraception for all patients is
oral and written informed consent,” stated senior author Lawrence McCullough,
PhD, of the Center for Medical Ethics and Health Policy, Baylor College of
Medicine.

The authors explain that compulsory sterilization
programs existed in the U.S. until the middle decades of the 20th century.
Initially, these programs targeted intellectually disabled and mentally ill
patients; however, many African American women and deaf, blind, epileptic,
physically deformed, and low-income women were sterilized against their will.
In 1979, U.S. federal legislation was enacted that aimed to enhance women’s
health rights by regulating the process of consent and documentation before
receiving surgical sterilization (both tubal sterilization and hysterectomy)
that is publicly funded.

“The intent was good, but the unintended consequence four
decades later is to restrict access based on source of payment,” noted lead
author Amirhossein Moaddab, MD, Visiting Post-Doctoral Fellow in the Department
of Obstetrics and Gynecology, Baylor College of Medicine. “The reality of
clinical practice is that nearly 50% of annual deliveries are paid for by
Medicaid and therefore necessitate the signed federal consent form and waiting
period.”

The authors discuss the concept of health care justice in
professional obstetric ethics and explain how it originates in the ethical
concepts of medicine as a profession and of being a patient. They also explore
its deontologic and consequentialist dimensions. The “deontologic” or
“rule”-based dimension judges the morality of an action based on its adherence
to a rule or rules. The “consequentialist” dimension judges the morality of an
action on its consequences.

“We conclude that Medicaid policy allocates access to
elective tubal sterilization differently, based on source of payment and
gender, which violates health care justice in both its deontologic and
consequentialist dimensions,” said senior author Frank A. Chervenak, MD, of the
Department of Obstetrics and Gynecology, Weill Medical College of Cornell
University/New York-Presbyterian Hospital. “Obstetricians should invoke health
care justice in women’s health care as the basis for advocacy for needed change
in law and health policy, to eliminate health care injustice in women’s access
to elective tubal sterilization.”

Commenting on the article, noted expert Philip Darney,
MD, MSc, Distinguished Professor of Obstetrics, Gynecology, and Reproductive
Sciences at the University of California, San Francisco and Director of the
Bixby Center for Global Reproductive Health, added, “Childbirth provides a
convenient and economical opportunity for permanent contraception. This
opportunity is denied to about 60,000 of the women who select it every year
because of rules that the public insurance consent process applies to those who
need their post-partum sterilizations paid for by Medicaid.”

Dr. Darney emphasized that when women cannot present
evidence of having met the 30-day requirement the consequences to them can be
severe: half of those who never intended to become pregnant again do so, nearly
20% within a year. Some of these women have pregnancy-associated illnesses like
diabetes and hypertension that make subsequent pregnancies risky. “A
‘post-partum tubal’ is the easiest (and cheapest) way for them to avoid
recurring illness. Individual obstetricians and their professional
organizations should protest the injustice, describe the health and financial
costs of the current consent process, and prevail on government health care
officials to change the regulations. The arguments of McCullough, Chervenak,
and colleagues will provide excellent background for official deliberations,”
he concluded.

About the American Journal of Obstetrics &
Gynecology The American Journal of Obstetrics & Gynecology
(www.AJOG.org),
known as “The Gray Journal,” presents coverage of the entire spectrum of the
field, from the newest diagnostic procedures to leading-edge research. The
Journal provides comprehensive coverage of the specialty, including
maternal-fetal medicine, reproductive endocrinology/infertility, and
gynecologic oncology. It also publishes the annual meeting papers of several of
its eight sponsoring societies, including the Society for Maternal-Fetal
Medicine and the Society of Gynecologic Surgeons.

The American Journal of Obstetrics & Gynecology's
2013 Impact Factor is 3.973. The journal now ranks second in Eigenfactor score,
and continues to be first in total citations and the number 5 journal in the
Obstetrics & Gynecology category according to the 2013 Journal Citation
Reports®, published by Thomson Reuters, 2014. The journal has also been recognized
as one of the 100 most influential journals in Biology & Medicine over the
last 100 years, as determined by the BioMedical & Life Sciences Division of
the Special Libraries Association (2009).

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